Since the offending act is an exercise in power and control
perpetrated by an anti-social, conduct-disordered, manipulative, deviant
person, descriptors of the treatment of choice include confrontation,
insistence on accountability for the offending behavior, a punitive
rather than therapeutic orientation, and a focus on self-disclosure and
the acquisition of strategies to prevent relapse" (Goocher, 1994,
p. 244)

With a description of treatment such as the one provided above by
Goocher (1994), it would not be surprising to learn that, in some
jurisdictions, adolescents who have committed sexual crimes have
routinely been removed from their homes--regardless of the nature of
their crimes--subjected to polygraph and penile plethysmograph (PPG)
examinations, aggressively and repeatedly confronted regarding the
details of their past sexual crimes, and asked to engage in
punishment-based behavioral procedures--designed for adults--that are
intended to alter their presumed deviant sexual arousal. In some parts
of the world, such as the U.S., adolescents who offend sexually have
also been subjected to registration and community notification laws in
the hopes of protecting people from being victimized by these youth
(Zimring, 2004). This has not how professionals have always viewed
adolescents who have committed sexual crimes, however. Indeed, in some
of the earliest academic reports from the 20th century, it was pointed
out that these youth are in fact heterogeneous with respect to many
different variables and that there was no singular treatment goal or
approach that would universally apply for youth who have engaged in this
behavior (e.g., Atcheson & Williams, 1954; Doshay, 1943; North,
1956; Waggoner & Boyd, 1941). This view seemed to change fairly
quickly in the early 1980s, however, when it was more widely recognized
that many adults who offended sexually began offending sexually as
adolescents (e.g. Abel, Mittelman, & Becker, 1985; Longo &
Groth, 1983). Given that there were already well-established assessment
and treatment procedures developed for adults who offended sexually,
many of the early treatment programs for adolescents mimicked adult
programs--with a particular focus on the assessment and punishment of
deviant sexual arousal and confrontational approaches to extract details
of past sexual offenses (Knopp, 1982). This blind application of the
adult-based assessment and treatment approaches of the day was likely
attributable to the fact that the sexual crimes committed by adolescents
looked behaviorally similar in nature to the sexual crimes committed by
adults, despite the fact that there are rather obvious and critical
developmental differences regarding not only sexual functioning (e.g.,
Bancroft, 2006; Bukowski, Sippola, & Brender, 1993) but, more
importantly, the cognitive process that impact social and emotional
functioning (Steinberg, 2010).

It is argued herein that, since the early 1980s, five assumptions
have fueled the assessment, treatment, and management of adolescents who
have offended sexually. These assumptions are referred to herein as the
"5 Ds": (1) deviant, (2) delinquent, (3) disordered, (4)
deficit-ridden, and (5) deceitful. Although there have been some shifts
in thinking over the past three decades, and there are many locations in
the world where youth who have offended sexually are not subjected to
polygraphs and PPGs, placed on public registries, or asked to partake in
untested, punishment-based procedures to alter sexual interests, these
beliefs unfortunately continue to inform clinical practices and laws in
many jurisdictions. This is particularly unsettling, however, given that
there is very little empirical support for these assumptions.

* They Are All Sexually Deviant, Aren't They?

Perhaps the assumption that has had the most influence on the
assessment and treatment of adolescents who offend sexually is the
notion that they can all be characterized by deviant sexual interests:
i.e., sexual interests in prepubescent children and/or sexual violence.
A brief perusal of treatment manuals, textbooks, and journal articles
written in the 1980s and 1990s would certainly lead one to believe that
all adolescents who have offended sexually are sexually deviant. For
example, Perry and Orchard (1992) stated that a goal for all adolescents
who offend sexually is to "learn more appropriate sexual
preferences" (p. 64). Lakey (1994) explained that "other
important treatment issues involve changing deviant sexual fantasies and
masturbatory practices" (p. 758). Similarly, in their description
of treatment, Hunter and Santos (1990) concluded that
"insight-oriented approaches for the treatment of these youth are
of limited value ... key components include the reduction of deviant
arousal via satiation therapy and the use of covert sensitization"
(p. 240).

Furthermore, in the 1993 National Task Force Report from the
National Adolescent Perpetrator Network (National Task Force on Juvenile
Sexual Offending), it was pointed out that every sexually abusive youth
should understand the role of sexual arousal in their sexual offending
and should reduce their deviant sexual arousal. The American Academy of
Child and Adolescent Psychiatry (Shaw, 1999) also argued that decreasing
deviant sexual arousal is an integral component of treatment for all
youth who have offended sexually. It should not be surprising,
therefore, that most specialized treatment programs for adolescents in
the UK and the Republic of Ireland (Hackett, Masson, & Phillips,
2006), and in Canada and the U.S. (McGrath, Cumming, Burchard, Zeoli,
& Ellerby, 2010), address deviant sexual interests in some fashion.

It should be stressed, however, that there is very little evidence
to support the assumption that most adolescents who offend sexually
actually have deviant sexual interests. Looking at research where
investigators have used the penile plethysmograph (PPG), a tool
developed to assess adult male sexual interests (Freund, 1991), Seto,
Lalumiere, and Blanchard (2000) reported that only 25% of the adolescent
males in their investigation demonstrated maximal sexual interest in
prepubescent children. With an overlapping and augmented sample, Seto,
Murphy, Page, and Ennis (2003) noted that just 30% of adolescent males
who had offended sexually responded equally or more to child stimuli
during PPG assessments.

In two investigations using clinician ratings, it was also found
that a minority of adolescent males who offended sexually could be
described as evidencing deviant sexual interests. In the first study
(Worling, 2004) , structured ratings from several clinicians who used
the Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR;
Worling & Curwen, 2001) were examined, and it was found that only
36% of the participants were rated as having sexual interests in
prepubescent children and/or sexual violence. A majority of the
adolescents in that investigation were residents in a residential
treatment center in the Northern U.S. designed to address the needs of
high-risk youth. More recently, in a prospective validation study of the
ERASOR (Worling, Bookalam, & Litteljohn, 2012) it was found that
only 39% of adolescent males who had offended sexually were rated by a
number of different clinicians as demonstrating sexual interest in
prepubescent children and/or sexual violence.

There was one investigation in which the authors concluded that 60%
of the adolescents studied had deviant sexual fantasies at the outset of
the study and that this somehow increased to 90% after 3 months in
treatment (Aylwin, Reddon, & Burke,

2005) . It is critical to point out, however, that the authors
considered it deviant if adolescents were fantasizing about the staff in
the residence--regardless of the age of the staff and the nature of the
sexual fantasy. As such, it is unclear what proportion of self-reported
fantasies in that investigation actually involved prepubescent children
or sexual violence.

Overall, therefore, the available research indicates that,
depending on the sample studied, approximately 60-75% of adolescent
males who have offended sexually are, in fact, maximally sexually
interested in consensual activities with age-appropriate partners.
Although deviant sexual arousal likely plays a role in the etiology
and/or maintenance of adolescent sexual offending for some adolescents,
there are obviously other factors to consider such as intimacy deficits,
antisociality, and access and opportunity, for example. This is not to
minimize the role of deviant sexual interests altogether, as it is clear
that some adolescents who have offended sexually are clearly sexually
interested in prepubescent children and/or sexual violence, and there is
evidence to suggest that deviant sexual interest is a risk factor for
adolescent sexual recidivism (Worling & Langstrom, 2006).

In their meta-analysis, Seto and Lalumiere (2010) found that,
relative to adolescents who committed nonsexual crimes, adolescents who
offended sexually were more likely to be characterized by "atypical
sexual interests." It is important to point out, however, that
there was significant heterogeneity in effect sizes in their analysis
and that this factor was made up of several diverse variables, including
prior sexually abusive behaviors, sexual preoccupation, and
cross-dressing, for example. Furthermore, although the moderate effect
size informs us that adolescents who offend sexually are more likely to
have "atypical sexual interests" relative to adolescents who
offend nonsexually, it does not give us any indication of the absolute
level of "atypical sexual interest" in either group.

Do All Sexually Abusive Youth Demonstrate Deviant Interests?

During the second year of my career in this field, in the late
1980s, I had the good fortune to learn some valuable lessons from an
adolescent client. In particular, I was working with an adolescent who
had sexually abused two younger female siblings. After a number of
months during which we had worked on goals such as awareness of the
impact of sexual offending, repairing the sibling relationships,
increasing his sense of responsibility/accountability, enhancing his
interpersonal intimacy with peers, enhancing his relationship with his
mother (his father was not involved in his life), and reducing the
impact of his early childhood trauma, I unfortunately assumed that I
should perhaps address his presumed deviant interest in children. I
taught him the finer points of covert sensitization, as outlined in
various contemporary texts (e.g., Carey & McGrath, 1989; Maletzky,
1991), and the youth managed to produce an audiorecording of a single
session for our next meeting. In particular, his recording included a 3
minute sexual offense script, a 3 minute punishment script, and then a 3
minute reward/relaxation script. While listening to the audio recording,
not only was I suddenly horrified to think that I had actually asked
this 16-year-old to make a recording of his deviant sexual thoughts, but
I started to wonder about potential problems related to privacy and
security of the recording. I also wondered about the fact that this
homework assignment could perhaps unwittingly reinforce deviant
fantasies. Fortunately for both of us, I also noticed that the
youth's recorded voice sounded quite inauthentic during the first
few minutes. When I asked him about this during our next meeting, he
informed me that he was actually inventing a sexual fantasy regarding a
young child, as he has never been sexually aroused by young children. He
added that he felt that we had a good working relationship, and he was
afraid that I would terminate his therapy if he did not make up a
deviant sexual interest in prepubescent children and told me that he
actually never had such an interest.

I was very fortunate that this adolescent taught me three important
lessons early on in my career: (a) the therapeutic alliance is
incredibly important, (b) not all adolescents who have offended against
young children are sexually aroused by young children, and (c) treatment
techniques designed for adults have the potential for iatrogenic harm
when applied to adolescents. I was also fortunate that the program that
I have worked at for the past 25 years started out as a treatment
program for adolescent survivors of sexual abuse--not as a treatment
program for adult males who offended sexually. As such, most of the
assessment and treatment approaches that were utilized there--even in
the 1980s and 1990s--were sensitive both to adolescent development and
trauma.

The Treatment of Adolescent Sexual "Deviancy"

In my recent review of the literature (Worling, 2012), I pointed
out that punishment-based approaches are the most common treatment
described in the literature for addressing deviant sexual arousal. The
majority of these behavioral treatments were actually developed for use
with adult males, and there are many questions regarding their use with
adolescents. Take masturbatory satiation (Marshall, 1979), for example.
With this procedure, an adult client is instructed first to masturbate
to a nondeviant sexual fantasy. He or she is then instructed to
immediately attempt to masturbate to one of his or her deviant sexual
fantasies. The assumption underlying this approach is that the
masturbatory behavior immediately following climax is going to be
unpleasant and, as such, the individual will gradually associate his or
her deviant sexual fantasy with a significantly diminished drive state
(Maletzky, 1991). Given that the refractory period for adolescent males
can be extremely short (Bancroft, 2009), it is possible that this
procedure could actually serve to strengthen an adolescent's
deviant fantasies. It is also crucial to point out that there are no
controlled investigations of the effectiveness of this treatment for
youth aged 12 to 18.

Another treatment approach designed to extinguish deviant sexual
arousal among adult males is aversive behavioral rehearsal
(Wickramasekera, 1976). This technique has also been called "shame
aversion therapy" (Serber, 1970), and clients engaged in this
treatment are taught to pair their deviant sexual fantasies with intense
shame and/ or anxiety. Presently, approximately 15% of treatment
programs in the USA for adolescents who have offended sexually employ
this technique (McGrath et al., 2010). Not only is there is no empirical
support for this technique with adolescents, but there is a general
consensus amongst professionals that shame actually inhibits treatment
effectiveness for individuals who have offended sexually by increasing
defensiveness and social withdrawal (e.g., Association for the Treatment
of Sexual Abusers, 2001; Bumby, Marshall, & Langton, 1999; Jenkins,
2005; Proeve & Howells, 2002; Ward, Day, Howells, & Birgden,
2004; Worling, Josefowitz, & Maltar, 2011). Other punishment-based
techniques designed for adult males who have offended sexually, such as
covert sensitization (Cautela, 1967), minimal arousal conditioning
(Jensen, 1994), and olfactory aversion (Colson, 1972), are also still
utilized with adolescents to reduce their deviant sexual arousal
(McGrath et al., 2010), despite the fact that there are no controlled
investigations of their efficacy with this age group--or of their
potential for iatrogenic harm.

In addition to techniques designed to punish deviant sexual
interests, there are also some behavioral procedures that have been
developed to enhance nondeviant sexual interests. Procedures such as
orgasmic conditioning (Maletzky, 1991) or orgasmic reconditioning
(Marquis, 1970), for example, require the individual to masturbate to
nondeviant fantasies and/or imagery. As in the case of punishment-based
procedures, however, there have been no controlled investigations of the
positive (or negative) impact of these approaches with adolescents,
despite the fact that some programs continue to utilize them (McGrath et
al., 2010).

Of course, there are also a number of ethical concerns regarding
the use of any behavioral techniques with adolescents to alter sexual
interests. For example, is it ever appropriate to use masturbation in
treatment for adolescents who have offended sexually? How can treatment
materials and homework tasks be safeguarded during treatment? How can a
therapist ensure compliance when a client is utilizing masturbatory
procedures? At what age can a youth truly consent to these procedures?
Given that adolescents are still developing and refining their sexual
interest and identities (Bancroft, 2006), how can one safeguard against
potential iatrogenic harm? What about the possibility that we might
inadvertently be encouraging an adolescent to create and reinforce
deviant sexual scripts?

Another popular approach in the treatment of deviant sexual is
thought stopping, or urge suppression (e.g., Hunter, 2011; Kahn &
Lafond, 1988). With this technique, the adolescent is taught procedures
to push a deviant sexual thought out of conscious awareness by thinking
of an aversive experience or by picturing a distractor such as a stop
sign, for example. In their reviews of the literature regarding the
effectiveness of thought stopping, Johnston, Ward, and Hudson (1997) and
Shingler (2009) pointed out that there is often an ironic rebound effect
such that thoughts that are consciously suppressed in psychological
treatment approaches actually tend to intrude more frequently, and more
intensely, than had the thought-suppression intervention not been used
in the first place.

An alternative to teaching adolescents strategies to suppress
deviant sexual thoughts and urges is to teach clients mindfulness-based
approaches where they can learn simply to notice the thoughts and to let
the thoughts pass without acting on them. Some may believe that this is
a novel application of mindfulness-based cognitive therapy; however,
this treatment approach was actually a component of some of the earliest
specialized treatment programs (e.g., Steen & Monnette, 1989).
Although there has not yet been any research regarding the effectiveness
of this approach with adolescents who have offended sexually, there have
been supporting findings using mindfulness-based cognitive therapy with
adolescents to cope with stress (e.g., Biegel, Brown, Shapiro &
Schubert, 2009) and impulsivity (e.g., Semple, Lee, Rosa, & Miller,
2010). Singh et al. (2011) recently employed a multiple-baseline
investigation with a small sample of adult males with an intellectual
disability who had offended sexually against children, and they
demonstrated that mindfulness-based approaches impacted significantly on
deviant sexual arousal. Given that mindfulness-based approaches do not
involve punishment, masturbation, or shame, and that there is no
evidence to suggest that they would result in a rebound effect, they are
likely to be more readily embraced by both clients and therapists
relative to punishment and thought-stopping procedures, and particularly
if they can be supported with empirical evidence.

Medication is also used by a number of treatment programs to reduce
deviant sexual arousal for adolescents (McGrath et al., 2010); however,
there has yet to be a double-blind trial of any medication for this
purpose. In their review, Bradford and Federoff (2006) stressed that
there may be undesirable side effects if adolescents are prescribed
medications that have been used to control sexual behaviors in adults.
They also pointed out that most regulatory bodies do not currently
recognize the use of medication to reduce deviant sexual interests.

Given that (a) most adolescents who have offended sexually do not
evidence deviant sexual interests, (b) there is no clear empirical
support regarding treatment techniques aimed at reducing deviant sexual
arousal for adolescents, and (c) there are significant ethical concerns
regarding the use of thought-stopping procedures and behavioral
approaches to shape sexual interests, an alternative approach to address
deviant interests, if present, is to build skills for sexual health
(Worling, 2012). In other words, given the relative plasticity of sexual
arousal patterns during adolescence (Bancroft, 2006), there is a very
real possibility that nondeviant sexual interests can be strengthened if
adolescent clients see the possibility of forming emotionally and
sexually intimate relationships in their future. Some of the elements
that are necessary to achieve this goal include prosocial sexual
attitudes, positive knowledge regarding human sexuality, self-regulation
and decision-making skills, increased self-efficacy, and hope in a
healthy future. It should be stressed that many of these elements have
long been addressed in specialized treatment for adolescents who have
offended sexually (e.g., Steen & Monnette, 1989). Some adolescents
who display deviant sexual interests may also have significant barriers
to achieving interpersonal intimacy, such as social anxiety, or
dysfunctional beliefs regarding interpersonal relationships. In addition
to skill building, therefore, it is also important to reduce barriers
such as these.

In answer to our first question, then, it should be clear that
adolescents who have offended sexually are not all sexually deviant.
Indeed, from the extant research, it would appear that most of these
youth are most sexually interested in consenting activities with
age-appropriate partners. Naturally, some adolescents will evidence
deviant sexual interests, and this is a risk factor for continued sexual
offending. Despite the fact that many treatment programs utilize
behavioral techniques to alter sexual interests, there is no evidence
that they are actually effective with adolescents. More importantly,
there is a danger that these techniques could be harmful. For an
adolescent who demonstrates sexual interest in young children and/or in
sexual violence, it may be best to use mindfulness-based approaches
while simultaneously building the skills necessary for a healthy sexual
future.

* They Are All Just Delinquent, Aren't They?

Is it not the case that adolescents who have offended sexually have
broken the law and, therefore, that they should simply be viewed as
delinquent or antisocial youth? Is there really a need for specialized
assessment and treatment approaches? Do we not need simply to apply
generic tools and approaches designed for antisocial youth? There are
some (e.g., Letourneau & Miner, 2005; Milloy, 1998; Zimring, 2004)
who argue that there is little that is unique to adolescents who have
offended sexually and, thus, they question the wisdom of tailoring
assessment or treatment specifically for youth who have committed sexual
crimes. In support of this argument, it is often pointed out that there
is research to suggest that there are few, if any, differences between
youth who offend sexually and youth who offend nonsexually (e.g.,
Caldwell, Ziemke, & Vitacco, 2008). For example, Lewis, Shankok, and
Pincus (1979) reported no significant differences on a host of variables
and test scores when they compared a sample of 17 adolescents who had
offended sexually with 61 adolescents who had offended violently.
Similarly, McCraw and Pegg-McNab (1989) found no differences in
personality scores when they compared 45 adolescents who offended
sexually to 45 adolescents with nonsexual charges. Recidivism statistics
(e.g., Caldwell, 2007) have also been used to point out that, when
adolescents who have offended sexually are charged with new crimes
following treatment, they are more often charged with nonsexual crimes.
It is essential, however, to be mindful of the fact that most survivors
of a sexual crime never report their victimization to authorities (e.g.,
Brennan & Taylor-Butts, 2008).

In an effort to determine if there is anything that differentiates
adolescents who commit sexual crimes from those who commit nonsexual
crimes, Seto and Lalumiere (2010) conducted a meta-analysis with studies
where investigators compared youth with sexual offenses to youth with
nonsexual offenses. In support of the argument that adolescents who
offend sexually are not particularly unique, there were certainly a
number of variables where there were no significant differences between
groups, such as antisocial attitudes, family relationship problems,
heterosocial skills deficits, general psychopathology, and nonabusive
sexual experiences. These findings would support the generalist argument
that adolescent sexual offending is simply a product of some underlying
antisocial process. However, Seto and Lalumiere also found many
important differences between the groups. For example, youth who
offended sexually were significantly more likely than youth who offended
nonsexually to be characterized by atypical sexual interests, socially
isolation, increased exposure to sexual media, a lower self-esteem,
elevated anxiety, and a history of sexual, physical, and emotional
abuse. Furthermore, those youth with nonsexual offenses were more likely
than those who offended sexually to associate with delinquent peers, use
illegal drugs/alcohol, and have a more extensive criminal history. These
aggregate findings certainly support the argument that adolescents who
have sexually offended are significantly different from those who offend
nonsexually on a number of important dimensions.

Of course, it is not argued here that all adolescents who offend
sexually share the characteristics outlined by Seto and Lalumiere in
their meta-analysis. Some adolescents who offend sexually will share
many markers of general delinquency, such as antisocial attitudes,
diverse criminal history, substance use, academic underachievement, poor
self-regulation, etc. However, there are many other adolescents who have
offended sexually who show very few markers of antisociality--aside from
their sexual offending behaviors. Indeed, researchers have found that
there are distinct subgroups of adolescents who offend sexually where
antisociality is one of the key variables that differentiates the groups
(Smith, Monastersky, & Deisher, 1987; Richardson, Kelly, Graham,
& Bhate, 2004; Worling, 2001). In these three investigations, it was
found that there was one subgroup where an antisocial orientation was
the predominant characteristic; however, there were several other
subgroups where antisociality was not prevalent. Indeed, in each of
these investigations where subgroups were formed on the basis of
personality test data, researchers found that there were subgroups where
a prosocial orientation was predominant.

Research regarding risk assessment is also supportive of the notion
that there are key characteristics that differentiate adolescents who
offend sexually from the more general population of adolescents in
conflict with the legal system. Although a number of risk factors for
sexual recidivism, such as impulsivity, antisociality, and social
isolation, are also found in tools designed to predict general,
adolescent criminal recidivism (e.g., Hoge & Andrews, 2011), there
are several risk factors unique to continued sexual offending, such as
deviant sexual interests, deviant sexual attitudes, and sexual
preoccupation, for example (Worling & Lngstrom, 2006). There have
been a number of risk assessment tools developed specifically to address
the risk of sexual recidivism for adolescents, such as the ERASOR
(Worling & Curwen, 2001), the Juvenile Sex Offender Assessment
Protocol (J-SOAP II; Prentky & Righthand, 2003), the Juvenile Risk
Assessment Tool (J-RAT; Rich, 2007), and the Juvenile Sexual Offense
Recidivism Risk Assessment Tool-II (JSORRAT-II; Epperson, Ralston,
Fowers, DeWitt, & Gore, 2006). It has been found that measures
designed specifically to predict adolescent sexual recidivism perform
better relative to more generic measures of criminal and/or violent
behavior in youth (Viljoen, Mordell, & Beneteau, 2012). It is not
being argued here that adolescents who sexually offend are prosocial
save their sexual crimes. Rather, there are simply no data to support
the assumption that they are all antisocial, or even that most of them
can be described as characteristically delinquent. As in the case of
deviant sexual interests discussed above, it is important for those
working with adolescents who have sexually offended to determine whether
or not an antisocial orientation is present in each case. If an
adolescent who has offended sexually does have many markers of
delinquency (e.g., affiliation with delinquent peers, substance use,
procriminal attitudes), then treatment and management efforts should
obviously be aimed at addressing these issues. Otherwise, this would not
be necessary, and there could possibly be iatrogenic harm if prosocial
youth are required to participate in interventions designed to target
criminogenic factors for antisocial youth.

* They Are All Psychiatrically Disordered, Aren't They?

It must be a natural assumption for the layperson that a teenager
who has committed a sexual crime must have a psychiatric disorder of
some kind, and particularly if the youth has offended sexually against a
young child. Why else would he or she have committed such a heinous act?
Surely it is not the case that "normal" adolescent males and
females would ever commit sexual crimes? There must be some mental
disorder that leads a teen to commit a sexual crime.

Becker, Kaplan, Cunningham-Rathner, and Kavoussi (1986) reported on
the psychiatric diagnoses given by one practitioner to 19 adolescent
males referred to a state psychiatric institute as a result of incest
offenses. It was found that 14 of the adolescents had some type of
psychiatric diagnosis, with 12 of these youth qualifying for a diagnosis
of Conduct Disorder. The next most common diagnosis was Attention
Deficit Hyperactivity Disorder (ADHD), and this was identified for five
(26%) of the participants. Galli et al. (1999) similarly reported on
psychiatric diagnoses given to 22 adolescent males who had offended
sexually and who had been recruited from residential treatment programs.
As in Becker et al. (1986), Conduct Disorder was diagnosed for most of
the participants (16 of 17). However, 100% of the participants in this
investigation were also diagnosed with Pedophilia, and 71% (12/22) were
diagnosed with ADHD. This result contrasts sharply with Mazur and
Michael (1992) in their follow-up investigation with 10 adolescents who
had offended sexually, where they found that none of the participants
met diagnostic criteria for a paraphilia. Likewise, in their review of
adolescents seen at a psychiatric hospital in Canada, Saunders and Awad
(1988) stressed that "the vast majority of adolescent sexual
offenders do not fit the criteria of paraphilia" (p. 575).

The prevalence and nature of psychiatric diagnoses for this
population appear to vary considerably depending on the sample that is
selected and the diagnostic processes that are employed. Furthermore,
very few, if any, authors have reported on the reliability/validity of
the diagnostic tools that have been utilized, most investigations have
relied on a single diagnostician, and samples of adolescents have been
very small. It is also unclear in most of this research whether or not
diagnosticians have been blind to the criminal status of the youth.

In the meta-analysis completed by Seto and Lalumiere (2010), there
was little evidence to suggest that adolescents who offend sexually can
be described using specific psychiatric diagnoses, relative to other
adolescents involved in the criminal justice system. Although the
authors of the small studies cited above describe adolescents who offend
sexually as highly conduct disordered, there was no evidence to suggest
that those who offend sexually are any more antisocial than those
adolescents who commit nonsexual crimes. Indeed, as noted above, Seto
and Lalumiere found that those adolescents who offended nonsexually were
significantly more likely to have markers of antisociality, such as a
more extensive criminal history, associations with delinquent peers, and
drug/alcohol use. Furthermore, although adolescents who offended
sexually are more likely to exhibit heightened anxiety (not necessarily
an anxiety disorder, per se) and low self-esteem, there were no
differences between groups with respect to general psychopathology.

Once again, as in the case of both deviant sexual interests and
delinquency, there is no empirical support for the notion that
adolescents who offend sexually are all psychiatrically disordered.
Adolescent sexual offending is a behavior that reflects a choice that
the youth has made; it is not a function of a disorder, a disease, a
condition, or an illness. Of course, there may well be a psychiatric
diagnosis for some youth who have offended sexually, and the ability to
accurately describe a mental disorder should lead to more appropriate
and effective treatment. For example, given the increased prevalence of
sexual, physical, and emotional abuse relative to youth who have
offended nonsexually, it would not be surprising to learn that some
adolescents who have offended sexually experience Posttraumatic Stress
Disorder. Likewise, given that there is a subgroup where a delinquent
orientation is predominant, there will be some adolescents who offend
sexually where a diagnosis of Conduct Disorder is clearly evident, and
particularly for those youth who end up in correctional settings.

* They Are All Just Deficit-Ridden, Aren't They?

After reading many assessment reports prepared at various agencies
throughout North America since the 1980s, one might certainly believe
that adolescents who offend sexually can be described only by the long
list of deficits that have been catalogued during an assessment. This
is, perhaps, a result of a focus on risk, disorder, and deviance that
has pervaded this work. Of course, this may also have been the result of
the nature of the crime, as it may be particularly difficult for some
evaluators to look for strengths and assets in individuals who have
committed sexual crimes.

This focus on deficits has been prevalent in professional
publications for several decades, and the most commonly cited
characteristic of adolescents who offended sexually is that they have a
deficit with respect to social skills. For example, in their treatment
guidelines, Groth, Hobson, Lucey, & St. Pierre (1981) stated that
"juvenile sexual offenders need instruction in regard to developing
effective social skills and communication skills with age mates"
(p. 266). Similarly, Stops and Mays (1991) pointed out "that
adolescent sex offenders have at their core, deep-seated feelings of
inferiority, inadequacy, a lack of self-confidence, and immaturity"
(p. 101). Although the assumption that adolescents who offend sexually
are deficient in their social skills was very often forwarded in the
1980s and 1990s (e.g., Bagley & King, 1990; Burnett & Rathbun,
1993; Graves, Openshaw, & Adams, 1992; Groth & Loredo, 1981;
Saunders, Awad, & Levene, 1984; Stenson & Anderson, 1987;
Stevenson & Wimberley, 1990), a time when many treatment programs
were being developed, there are still some authors who make this
assumption (e.g., Hunter, 2011). Not surprisingly, treatment manuals
have been replete with instructional exercises for ameliorating this
supposed deficit in social skills. Of course, social skill deficits are
no more prevalent in populations of adolescents who commit sexual crimes
relative to adolescents who offend nonsexually (Seto & Lalumiere,
2010), and there are subgroups of adolescents who have offended sexually
who are actually quite skilled socially (Richardson et al., 2004; Smith
et al., 1987; Worling, 2001).

Perhaps another reason that clinicians have focused so heavily on
risks and deficits is a result of the fact that most of the research has
been focused on these topics, at the expense of a focus on strengths,
protective factors, and resiliency. This is not unique to the field of
sexual offending, as research into general criminal behavior has been
aimed almost exclusively on the identification of factors that predict
risk rather than on the identification of protective factors that
predict desistence from reoffending. This preoccupation with risk-only
factors in risk assessment tools, which also influenced my original
efforts (Worling & Curwen, 2001), has likely resulted in inaccurate
judgments by evaluators and therapists (e.g., Miller, 2006; Rogers,
2000). Far rington (2007) has stressed that researchers should enhance
the accuracy of violence risk assessments by also identifying factors
that are predictive of desistence.

Unfortunately, there have been very few investigations designed to
identifying protective factors for adolescent sexual recidivism. In
1998, Bremer developed the Protective Factors Scale to assist with
placement decisions for youth who had offended sexually; however, this
tool has not been subjected to empirical scrutiny. There has, on the
other hand, been some initial work regarding the identification of
protective factors for general youth violence. Preliminary, multi-site
research from the Centers for Disease Control and Prevention (Hall,
Simon, Lee, & Mercy, 2012) suggests that factors such as academic
achievement, prosocial peer relationships, positive family management,
and attachment to school may operate to reduce the onset of general
youth violence. These authors stress, however, that firm conclusions
regarding protective factors cannot be drawn at this time given the
paucity of research at this point.

The Structured Assessment of Violence Risk in Youth (SAVRY; Borum,
Bartel, & Forth, 2006) is a widely-used, risk assessment tool that
contains 24 risk and 6 protective factors. Although there is preliminary
evidence from investigations with adolescents to suggest that these
protective factors are related to desistence in general criminal
recidivism (Rennie & Dolan, 2010) and violent recidivism (Lodewijks,
Ruiter, & Doreleijers, 2010), the SAVRY protective factors are not
related to desistence of adolescent sexual recidivism (Schmidt,
Campbell, & Houlding, 2011; Spice, Viljoen, Latzman, Scalora, &
Ullman, 2012). This suggests that there are unique protective factors
that are predictive of desistence for adolescent sexual reoffending.
This is not surprising given that there are unique risk factors for
adolescent sexual recidivism (Worling & Lngstrom, 2006). Possible
protective factors for adolescent sexual recidivism include factors that
are both sexual offense-specific (e.g., prosocial sexual interests,
prosocial sexual attitudes, and prosocial sexual environment) and sexual
offense-related (e.g., compassion for others, emotional intimacy with
peers, and positive problem-solving skills) (Worling, 2013).

A Shift in Focus: Strengths and Protective Factors

In addition to the recent empirical quest to identify protective
factors for adolescent sexual recidivism (e.g., Spice et al., 2013;
Worling & Langton, 2013), there has also been a more conscious shift
towards strength-based approaches; in part, perhaps, as a result of the
Good Lives Model (Ward, 2002; Ward & Stewart, 2003). According to
this model, the goal of treatment is to provide the individual with the
means to achieve primary human goods, which are conditions that would
allow one to achieve an enhanced sense of well-being and purpose, such
as happiness, creativity, spirituality, and knowledge, for example. This
model has recently been examined with specific reference to adolescents
who have offended sexually (Chu, Hoh, Zeng, & Teoh, 2013); however,
it is important to stress that a strength-based approach has been
advocated for many years in work with this population.

More specifically, despite the unfortunate focus on deviance,
disorder, deficit, and deceit that has plagued the field, many programs
have also simultaneously stressed the need to build positive
self-regulation skills (Lee & Olender, 1992), social skills
(Margolin, 1983), positive sexual knowledge (Becker, 1990), and healthy
family relationships (Steen & Monnette, 1989), for example. Indeed,
Rich (2006) remarked that the need to enhance relationship skills,
self-regulation, self-agency, and decision making has long been part of
treatment programs that have taken a more holistic and integrated view
of youth who have sexually offended in contrast to those programs that
have had a more myopic focus on the sexual offending.

In sum, it is obviously not the case that adolescents who sexually
offend can be described only by their deficits. It may be, once again,
that the nature of the crime has propelled researchers and clinicians to
focus almost exclusively on deficits rather than on assets and
protective factors. Alternatively, this orientation may be more
reflective of the assumption that these youth are inherently deviant,
delinquent, disordered, and deceitful. Efta-Breitbach and Freeman (2004)
remarked that, although some current treatment goals are consistent with
a strength-based approach that would foster resilience in adolescents
who have offended sexually, there is dire need to more methodically
understand and promote resilience and competence and focus on strengths
and positive behaviors.

* They Are All Deceitful, Aren't They?

In speaking about treatment for adolescents who commit sexual
offenses, Margolin (1983) remarked that "the need to control others
pervades the offender's every social interaction. The most
prominent symptom of this compulsion to control is his [sic] proclivity
to lie" (p. 3). In a similar vein, Perry and Orchard (1992) stated
that "adolescent sex offender work is very demanding and stressful.
Clinicians are working with clients who attempt to deny, minimize, or
rationalize the extent of their problems" (p. 29). According to
Barbaree and Cortoni (1993), "the first stage in treatment targets
denial and minimization and successful completion of this stage is a
prerequisite to successful treatment" (p. 255).

It should not be surprising, therefore, that there is typically a
call for clinicians and probation officers to be diligent in their
efforts to confront the denial and minimization of these adolescents to
ensure that they will come clean with the details of their past sexual
crimes and/or their current sexual deviance (e.g., Bethea-Jackson &
Brissett-Chapman, 1989; Ferrara & McDonald, 1996; Kahn & Lafond,
1988; Lakey, 1994; National Task Force on Juvenile Sexual Offending,
1993; Sermabeikian & Martinez, 1994; Shaw, 1999; Way &
Balthazor, 1990). This demand for adolescents to acknowledge all details
of their past sexual offending and current sexual deviance is likely
based, at least in part, on the prevailing sentiment that one must first
acknowledge a problem before it can be treated. Of course, it may also
reflect the difficulty that some practitioners have separating the
person from the behavior; the need to use aggressive confrontation,
shame, and punitive approaches may simply reflect anger towards the
youth for the criminal sexual behavior.

Without minimizing the significant harm that can result for the
survivor and his or her family, it is important to note that a sexual
crime is likely to lead to significant shame, embarrassment, and guilt
for the adolescent who has offended--in addition to significant
personal, family, legal, and social consequences. It would be unusual,
therefore, to expect any individual to readily provide a detailed
account of past sexually abusive behaviors and/or current deviant sexual
thoughts and fantasies--especially at the outset of a relationship with
another individual. As such, minimization and denial are likely a
natural phenomenon connected to the nature of the crime, rather than a
pathological characteristic of the adolescent who has offended sexually.

Given this push for adolescents who have offended sexually to
confess all of the details of their past sexual crimes, it should not be
surprising to find that many authors have advocated for therapists to
use confrontational approaches in treatment to break through denial and
minimization (e.g., Baird, 1991; Burnett & Rathbun, 1993; Goocher,
1994; Groth et al., 1981; Hird, 1997; National Task Force on Juvenile
Sexual Offending, 1993; Perry & Orchard, 1990; Sermabeikian &
Martinez, 1994; Smets & Cebula, 1987). In their review of the
literature, however, Marshall et al. (2003) pointed out that a
confrontational approach is actually likely to increase defensiveness
and resistance for individuals who have offended sexually. Marshall et
al. suggested instead that the best approach to address minimization and
denial in treatment is to supportively challenge individuals when
necessary rather than to use a confrontational approach. They also noted
that research points to the fact that therapeutic interventions are
actually more effective when the therapist is empathic, warm, genuine,
and rewarding.

Getting to the "Truth"

The view that adolescents who offend sexually lie and deceive is
perhaps best exemplified in the U.S. where 50% of treatment programs
presently use the polygraph (McGrath et al., 2010). McGrath et al.
pointed out that this represents a marked increase in the use of the
polygraph in recent years, as only 22% of treatment programs for
adolescents who offended sexually used the polygraph in the U.S. in
1996. Chaffin (2011) has stressed that the polygraph is seldom used with
youth in the U.S. who commit nonsexual crimes, and that there are
actually very few countries outside of the U.S. where the polygraph is
utilized with any adolescents. Chaffin (2011) and Prescott (2012) have
outlined a number of significant concerns regarding the use of the
polygraph with adolescents who have offended sexually. In addition to
the complete lack of empirical support for the reliability and validity
of the approach, they also underscore the significant potential for harm
to the adolescent including the coercive nature of a polygraph
examination and the replication of an abusive experience, the increased
likelihood of false confessions in an effort to satisfy program
requirements, and the dubious ethics that result from the use of an
interrogation procedure with youth in compulsory treatment.

The argument that is often forwarded in support of the utility of
the polygraph is that this procedure will result in the identification
of survivors of sexual abuse who have previously been unknown to
authorities. There have been only two published studies with adolescents
where this issue has been examined. In the first paper, Emerick and
Dutton (1993) reported that adolescents disclosed an average of almost
one (M=0.98) new victimized individual as a result of a polygraph
examination. In a similar investigation, Van Arsdale, Shaw, Miller, and
Parent (2012) also found that adolescents who had offended sexually
disclosed an average of almost one (M=0.73) new survivor of sexual abuse
based on a polygraph examination. Although some might argue that these
data support the use of the polygraph with this population, this result
should be contrasted with research supporting the fact that adolescents
are more likely to disclose new information within the context of a
trusting therapeutic relationship. For example, Baker, Tabacoff,
Tornusciolo, and Eisenstadt (2001) found that adolescents in specialized
treatment disclosed an average of 3.3 new victimized individuals during
the course of discussions with their treatment providers. Prescott
(2012) also emphasized the fact that survivors of sexual abuse should be
free to disclose when and how they choose and that some may not wish to
be identified via the results of a polygraph examination.

With this pressure for youth to acknowledge details of past sexual
crimes, it is also important to highlight the fact that there is
presently no empirical evidence to support the notion that it is
necessary for future sexual health for adolescents to acknowledge all of
the details of all past sexual crimes. This is not, of course, to
suggest that adolescents need not take responsibility for their sexual
offending behaviors. Most practitioners would agree that it is important
for an adolescent to acknowledge that he or she has offended sexually
and that it is ideal if

they can be open regarding the identity of the people whom they
have abused and take responsibility for how they have harmed others.
However, there is just no scientific rationale for impelling youth to
confess all of the details of all of their sexual crimes.

Perhaps this focus on deception and denial has also somehow been
related to the assumption that adolescents who are denying their past
sexual offending are also at higher risk of reoffending sexually. A
number of risk-assessment guidelines (e.g., Prentky & Righthand,
2001; Ross & Loss, 1988) list denial of sexually abusive behaviors
as a risk factor; however, there is no research to support the notion
that denial at the point of assessment is predictive of sexual
recidivism for adolescents (Worling & Lngstrom , 2006; but also see
Rich, 2009). Indeed, there is actually some evidence to suggest that
those adolescents who offend sexually and who are categorically denying
past offenses may actually be at a reduced risk of reoffending sexually
relative to those adolescents who are acknowledging their crimes (Kahn
& Chambers, 1991; Langstrom & Grann, 2000; Worling, 2002).

Honesty by Self-Report in Treatment

The notion that individuals who offend sexually are naturally prone
to deception and dishonesty is perhaps best contradicted by the
available research regarding the assessment of deviant sexual interests.
A layperson would naturally assume that individuals who have offended
sexually would be reluctant to be open regarding a sexual interest in
prepubescent children and/or sexual violence; however, authors of the
available research suggest otherwise. For example, with a sample of men
who offended sexually against children, Laws, Hanson, Osborn, and
Greenbaum (2000) found that self-reported sexual interests obtained via
a card-sort procedure were more accurate that penile plethysmograph
(PPG) data in identifying the gender of victimized individuals. In a
similar study, Day, Miner, Sturgeon, and Murphy (1989) found that
self-report data from a questionnaire regarding sexual thoughts,
feelings, and behaviors could accurately classify men according to the
gender of their children whom they abused.

Looking at research with adolescents, Seto et al. (2000) reported
that the self-report of a majority of youth acknowledging a sexual
interest in children during an interview was subsequently supported by
objective PPG examination. Similarly, Worling (2006) found that
self-report indices and procedures were able identify those adolescents
who sexually abused children. Using a self-report questionnaire,
Daleiden, Kaufman, Hilliker, and O'Neil (1998) also reported that
adolescents who offended sexually disclosed significantly more deviant
sexual behaviors relative to both adolescents who offended nonsexually
and adolescents with no criminal histories. These studies each lend
support for the idea that adolescents in treatment for sexually abusive
behavior are able to engage honestly and that self-report is a valuable
and viable means by which to learn about the sexual behaviors and
interests of youth in treatment.

To answer to our final question, then, it is not always the case
that adolescents who offend sexually lie and deny. Indeed, it would
appear that many of these youth are able to identify previously
undisclosed sexual crimes within the context of a trusting therapeutic
relationship, and many are also forthcoming with respect to their sexual
interests when evaluators use structured, self-report procedures. There
is also no compelling evidence to suggest that it is necessary for
adolescents to disclose all of the details of their past sexually
abusive behaviors, or that denial is predictive of continued sexual
offending. When adolescents are struggling to acknowledge information
that is likely to lead to shame, embarrassment, and significant
personal, legal, and familial consequences, it is important that
professionals employ supportive rather than confrontational approaches.

* Conclusion

Interventions with adolescents who have committed sexual crimes
have been influenced for the past several decades by the belief that
these youth are inherently sexually deviant, delinquent, disordered,
deficit-ridden, and/or deceitful. This is likely related, in part, to
the rather blind application of the adult-based techniques and
approaches that were popular in the 1980s. It should be no surprise,
therefore, that many of these adolescent have been removed unnecessarily
from their homes, confronted aggressively regarding the details of their
past sexual crimes, wired up to physiological measurement devices that
have questionable scientific merit, and subjected to untested
interventions designed to alter presumed deviant sexual interests.

There are likely some professionals who believe that the nature of
the crime merits such an aggressive and punitive approach, that these
youth have forfeited many of their human rights as a result of choosing
to commit a sexual crime, and that we should not be particularly
concerned about subjecting these youth to assessment and treatment
techniques that have little to no scientific credibility. However, there
is considerable danger if we let these assumptions persist and thereby
influence our responses to adolescent sexual offending. Indeed, as
outlined in this paper, these assumptions can lead to questionable
interventions that may actually increase the risk of continued sexual
offending. Take, for example, untested behavioral interventions designed
to decrease deviant arousal that could inadvertently establish and
strengthen novel, deviant sexual scripts; or consider a polygraph
interrogation that could result in heightened fear, false confessions,
and/or an unnecessarily protracted stay in a specialized residential
program.

There will obviously be some adolescents who have offended sexually
who display deviant sexual interests, and those who are also antisocial,
deceitful, disordered, and who have a number of significant deficits.
However, it is clear from the available research that there are many
adolescents who commit sexual crimes who have age-appropriate sexual
interests and who are prosocial, forthcoming regarding past offending
and current sexual interests, without psychiatric disorder, and who have
many strengths and putative protective factors. As a result, it is
critical that professionals examine the unique strengths, risks, and
needs of each adolescent and tailor treatment and supervision, if
necessary, accordingly (Worling & Langton, 2012). Furthermore, it is
important that we choose assessment and treatment approaches that have
been developed with sensitivity to adolescent cognitive, social, and
emotional development. Of course, it is also essential that we select
approaches that have an empirical basis and that do not risk iatrogenic
harm.

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England: Russell House.

Shaw, J. A. (1999). Practice parameters for the assessment and
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